TEIP11, TEIP11-PS
I/P SIGNAL CONVERTER | OI/TEIP11/TEIP11-PS-EN REV. M
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Appendix
Return form
Statement on the contamination of devices and components
Repair and/or maintenance work will only be performed on devices and components if a statement form has been completed and
submitted.
Otherwise, the device/component returned may be rejected. This statement form may only be completed and signed by authorized
specialist personnel employed by the operator.
Customer details:
Company:
Address:
Contact person:
Telephone:
Fax: Email:
Device details:
Type:
Serial no.:
Reason for the return/description of the defect:
Was this device used in conjunction with substances which pose a threat or risk to health?
Yes
No
If yes, which type of contamination (please place an X next to the applicable items):
biological
corrosive / irritating
combustible (highly / extremely
combustible)
toxic
explosive
other toxic substances
radioactive
Which substances have come into contact with the device?
1.
2.
3.
We hereby state that the devices/components shipped have been cleaned and are free from any dangerous or poisonous substances.
Town/city, date
Signature and company stamp
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